Original Article
RESULTS OF REVISION TOTAL KNEE ARTHROPLASTY USING PRESS-FIT CEMENTLESS STEM Maurício Masasi Iamaguchi1, Fernando Bley Vicente José Ricardo Pécora1, Gilberto Luis Camanho1
de
Castro Filho1, Riccardo Gomes Gobbi1, Luis Eduardo Passarelli Tirico1,
Abstract
Objective: To show our experience with press-fit cementless stem and metaphyseal fixation with cement in a selected series of patients who underwent revision total knee arthroplasty. Methods: Thirty-four patients (35 knees) underwent revision total knee arthroplasty using the press-fit technique. Minimum follow-up was one year (mean 2.2 years) with a maximum length of three years. Results: Of 34 patients, 20 were women and 14 were men. There was one death due to causes not related to arthroplasty and one patient dropout. There were no cases in which further review was necessary.
Patients who underwent revision had clinical and functional improvement demonstrated by the results of the KSS, results of the SF-36 quality of life questionnaire, through gains in range of motion and improved limb alignment. Conclusion: There was postoperative clinical and functional improvement in comparison to the preoperative status in revision total knee arthroplasty with press-fit cementless stem. Level of Evidence IV, Case Series. Keywords: Arthroplasty, replacement, knee. Osteoarthritis, knee. Knee prosthesis.
Citation: Iamaguchi MM, Castro Filho FBV, Tirico LEP, Gobbi RG, Pécora JR, Camanho GL. Results of revision total knee arthroplasty using press-fit cementless stem. Acta Ortop Bras. [online]. 2013;21(1):23-26. Available from URL: http://www.scielo.br/aob.
IntroduCTION
The revision of total knee arthroplasty is a challenging procedure that requires extensive surgical exposure, care in the implant extraction, restoration and correction of bone deficiencies minimizing complications to achieve satisfactory results. Although the results and longevity of primary total knee arthroplasty (TKA) have improved, the increase in the number of primary arthroplasties has required an increase in the number of and need for revision arthroplasties.1-4 The survival rate and clinical results of revision arthroplasty are inferior to primary knee arthroplasty.1,5-7 Use of extended stems is beneficial in the improvement of the survival rate and of the outcome of revision total knee arthroplasty.2,8-11 The objectives of the stems in revision arthroplasty are: endosteal reference for implant positioning; to pass bone defects; to increase implant fixation; and to reduce stress at the damaged bone interface in the distal femur and proximal tibia. Although the indication of revision arthroplasty is well defined by clinical and radiological parameters, the question arises whether the clinical and functional results will be satisfactory after the procedure. Our objective with this study is to answer the following ques-
tions: Was there a clinical and functional improvement according to the KSS? Was there an improvement in limb alignment? Was there an improvement in the range of motion? Was there an improvement in the patient’s quality of life according to the SF-36 questionnaire? MATERIAL AND METHODS
An analysis was conducted on information gathered prospectively in a consecutive series of cases. The patients under analysis had indications for non-constrained or semi-constrained revision total knee arthroplasty. The arthroplasties were performed in the period from 2006 to 2008 on a consecutive series of cases that included all the patients submitted to revision ® total knee arthroplasty in which an implant with Scorpio TS ® Total Knee Revision System (Stryker ) cementless press-fit stem implant was used. The characteristics of the implants allow their use in knees of a wide variety of sizes (implants ranging from size five to 11 were used here); femoral components with distal rotational/single posterior axis; femoral components with enlarged asymmetric anterior flange, with different components for the right and left sides; with two stem length options (80mm
All the authors declare that there is no potential conflict of interest referring to this article. 1 - Institute of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, SP, Brazil. Study conducted at the Laboratory of Medical Investigation of the Musculoskeletal System - LIM 41 of the Department of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo, SP, Brazil. Mailing address: Fernando Bley Vicente de Castro Filho. Rua Alves Guimarães, 643, apto 152. CEP: 05410-001. Brazil. Email: [email protected]
Article received on 3/16/2011 and approved on 6/16/2011. Acta Ortop Bras. 2013;21(1): 23-6
23
and 155mm); stems with varying diameters (10-19mm; 21mm and 23mm); stems that allow offset from 2 to 8 mm; polyethylene with thickness ranging from 10 to 24mm; with a central peg that limits varus and valgus movements up to 2°, allows rotational movement up to 10°, and allows a wide range of knee flexoextension; the implant also allows the use of 5, 10 and 15mm wedges for the distal femur, 5 and 10mm for the posterior femur, 5 and 10mm for the tibia. All the patients submitted to revision total knee arthroplasty, regardless of the reason, with the use of these implants with cementless femoral and/or tibial stem, were included in this study. Patients who were submitted to revision total knee arthroplasty with constrained implant, substitution of the polyethylene insert, or revision of the patellar component were excluded from the study. The failure mechanism was aseptic loosening in 19 knees and septic loosening in 14 knees, while no revisions due to instability or periprosthetic fractures were recorded. Bone tissue for culturing was collected in all the surgeries. Those patients in whom infection had already been evidenced in previous surgeries (surgical cleaning, insertion of spacers, and others) or those patients whose intraoperative culture at the time of the revision surgery was found to contain pathogens were considered cases of septic loosening. The Anderson Orthopaedic Research Institute (AORI) bone defect classification based on preoperative radiographs was recorded before the surgeries.12 The procedures were carried out at the Institute of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo in rooms with a vertical laminar flow that meet the requirements and comply with the current norms of the country’s regulatory agency, with adequate asepsis and antisepsis techniques. Serum hemoglobin was recorded before and after surgery, with the lowest recorded hemoglobin value. Total tourniquet, drainage output vacuum, need for blood transfusion and the total number of units of packed RBCs were also recorded. The size of the femoral and tibial components; the size and diameter of the stems used; the use of offset; the size and location of the femoral and tibial wedges used; and the size of the polyethylene used were all recorded as well. The surgical approach was the medial longitudinal route using previous incisions, employing the transquadriceps with medial arthrotomy with or without the crosswise cutting of the quadriceps tendon (quadriceps snip) in all the cases apart from one, in which tibial tuberosity osteotomy was used. The surgical technique used was that of hand milling of the medullary channel until good cortical bone contact was obtained, while the chosen stems had diameters 1mm larger than the diameter of the mill to obtain press-fit fixation in the tibial and femoral diaphyses. Bone cement (polymethyl methacrylate) was applied in the metaphyseal region of the components, leaving the stems uncemented. The postoperative radiographs were assessed in the frontal and lateral views of the knee; and in the panoramic view of the lower limbs. Alignment was analyzed according to the panoramic view (neutral, varus or valgus). Clinical evaluations were carried out using the Knee Society Score (KSS); evaluating the total range of motion of the knee;
24
and using the SF-36 questionnaire. These evaluations were performed prior to the surgery, and annually after the surgery. Cementless stems were used in the femoral and tibial component in all the cases (32) except for one, in which a stem was only used in the tibial component. RESULTS
Thirty-four patients (35 knees) who met the established criteria were included in the study. These were 20 women and 14 men with average age of 68.5 years (ranging from 45 to 82 years). There was one patient dropout and one death of cause not related to the arthroplasty (cerebral vascular accident one year after the arthroplasty). In the last follow-up there were 32 patients (33 knees) remaining in the study; 18 women and 14 men. The mean follow-up of the patients was 2.2 years, ranging from one to three years. The patients submitted to the revision with Scorpio® TS cementless press-fit stem presented significant clinical and functional improvement (p
RESULTS OF REVISION TOTAL KNEE ARTHROPLASTY USING PRESS-FIT CEMENTLESS STEM Maurício Masasi Iamaguchi1, Fernando Bley Vicente José Ricardo Pécora1, Gilberto Luis Camanho1
de
Castro Filho1, Riccardo Gomes Gobbi1, Luis Eduardo Passarelli Tirico1,
Abstract
Objective: To show our experience with press-fit cementless stem and metaphyseal fixation with cement in a selected series of patients who underwent revision total knee arthroplasty. Methods: Thirty-four patients (35 knees) underwent revision total knee arthroplasty using the press-fit technique. Minimum follow-up was one year (mean 2.2 years) with a maximum length of three years. Results: Of 34 patients, 20 were women and 14 were men. There was one death due to causes not related to arthroplasty and one patient dropout. There were no cases in which further review was necessary.
Patients who underwent revision had clinical and functional improvement demonstrated by the results of the KSS, results of the SF-36 quality of life questionnaire, through gains in range of motion and improved limb alignment. Conclusion: There was postoperative clinical and functional improvement in comparison to the preoperative status in revision total knee arthroplasty with press-fit cementless stem. Level of Evidence IV, Case Series. Keywords: Arthroplasty, replacement, knee. Osteoarthritis, knee. Knee prosthesis.
Citation: Iamaguchi MM, Castro Filho FBV, Tirico LEP, Gobbi RG, Pécora JR, Camanho GL. Results of revision total knee arthroplasty using press-fit cementless stem. Acta Ortop Bras. [online]. 2013;21(1):23-26. Available from URL: http://www.scielo.br/aob.
IntroduCTION
The revision of total knee arthroplasty is a challenging procedure that requires extensive surgical exposure, care in the implant extraction, restoration and correction of bone deficiencies minimizing complications to achieve satisfactory results. Although the results and longevity of primary total knee arthroplasty (TKA) have improved, the increase in the number of primary arthroplasties has required an increase in the number of and need for revision arthroplasties.1-4 The survival rate and clinical results of revision arthroplasty are inferior to primary knee arthroplasty.1,5-7 Use of extended stems is beneficial in the improvement of the survival rate and of the outcome of revision total knee arthroplasty.2,8-11 The objectives of the stems in revision arthroplasty are: endosteal reference for implant positioning; to pass bone defects; to increase implant fixation; and to reduce stress at the damaged bone interface in the distal femur and proximal tibia. Although the indication of revision arthroplasty is well defined by clinical and radiological parameters, the question arises whether the clinical and functional results will be satisfactory after the procedure. Our objective with this study is to answer the following ques-
tions: Was there a clinical and functional improvement according to the KSS? Was there an improvement in limb alignment? Was there an improvement in the range of motion? Was there an improvement in the patient’s quality of life according to the SF-36 questionnaire? MATERIAL AND METHODS
An analysis was conducted on information gathered prospectively in a consecutive series of cases. The patients under analysis had indications for non-constrained or semi-constrained revision total knee arthroplasty. The arthroplasties were performed in the period from 2006 to 2008 on a consecutive series of cases that included all the patients submitted to revision ® total knee arthroplasty in which an implant with Scorpio TS ® Total Knee Revision System (Stryker ) cementless press-fit stem implant was used. The characteristics of the implants allow their use in knees of a wide variety of sizes (implants ranging from size five to 11 were used here); femoral components with distal rotational/single posterior axis; femoral components with enlarged asymmetric anterior flange, with different components for the right and left sides; with two stem length options (80mm
All the authors declare that there is no potential conflict of interest referring to this article. 1 - Institute of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, SP, Brazil. Study conducted at the Laboratory of Medical Investigation of the Musculoskeletal System - LIM 41 of the Department of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo, SP, Brazil. Mailing address: Fernando Bley Vicente de Castro Filho. Rua Alves Guimarães, 643, apto 152. CEP: 05410-001. Brazil. Email: [email protected]
Article received on 3/16/2011 and approved on 6/16/2011. Acta Ortop Bras. 2013;21(1): 23-6
23
and 155mm); stems with varying diameters (10-19mm; 21mm and 23mm); stems that allow offset from 2 to 8 mm; polyethylene with thickness ranging from 10 to 24mm; with a central peg that limits varus and valgus movements up to 2°, allows rotational movement up to 10°, and allows a wide range of knee flexoextension; the implant also allows the use of 5, 10 and 15mm wedges for the distal femur, 5 and 10mm for the posterior femur, 5 and 10mm for the tibia. All the patients submitted to revision total knee arthroplasty, regardless of the reason, with the use of these implants with cementless femoral and/or tibial stem, were included in this study. Patients who were submitted to revision total knee arthroplasty with constrained implant, substitution of the polyethylene insert, or revision of the patellar component were excluded from the study. The failure mechanism was aseptic loosening in 19 knees and septic loosening in 14 knees, while no revisions due to instability or periprosthetic fractures were recorded. Bone tissue for culturing was collected in all the surgeries. Those patients in whom infection had already been evidenced in previous surgeries (surgical cleaning, insertion of spacers, and others) or those patients whose intraoperative culture at the time of the revision surgery was found to contain pathogens were considered cases of septic loosening. The Anderson Orthopaedic Research Institute (AORI) bone defect classification based on preoperative radiographs was recorded before the surgeries.12 The procedures were carried out at the Institute of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo in rooms with a vertical laminar flow that meet the requirements and comply with the current norms of the country’s regulatory agency, with adequate asepsis and antisepsis techniques. Serum hemoglobin was recorded before and after surgery, with the lowest recorded hemoglobin value. Total tourniquet, drainage output vacuum, need for blood transfusion and the total number of units of packed RBCs were also recorded. The size of the femoral and tibial components; the size and diameter of the stems used; the use of offset; the size and location of the femoral and tibial wedges used; and the size of the polyethylene used were all recorded as well. The surgical approach was the medial longitudinal route using previous incisions, employing the transquadriceps with medial arthrotomy with or without the crosswise cutting of the quadriceps tendon (quadriceps snip) in all the cases apart from one, in which tibial tuberosity osteotomy was used. The surgical technique used was that of hand milling of the medullary channel until good cortical bone contact was obtained, while the chosen stems had diameters 1mm larger than the diameter of the mill to obtain press-fit fixation in the tibial and femoral diaphyses. Bone cement (polymethyl methacrylate) was applied in the metaphyseal region of the components, leaving the stems uncemented. The postoperative radiographs were assessed in the frontal and lateral views of the knee; and in the panoramic view of the lower limbs. Alignment was analyzed according to the panoramic view (neutral, varus or valgus). Clinical evaluations were carried out using the Knee Society Score (KSS); evaluating the total range of motion of the knee;
24
and using the SF-36 questionnaire. These evaluations were performed prior to the surgery, and annually after the surgery. Cementless stems were used in the femoral and tibial component in all the cases (32) except for one, in which a stem was only used in the tibial component. RESULTS
Thirty-four patients (35 knees) who met the established criteria were included in the study. These were 20 women and 14 men with average age of 68.5 years (ranging from 45 to 82 years). There was one patient dropout and one death of cause not related to the arthroplasty (cerebral vascular accident one year after the arthroplasty). In the last follow-up there were 32 patients (33 knees) remaining in the study; 18 women and 14 men. The mean follow-up of the patients was 2.2 years, ranging from one to three years. The patients submitted to the revision with Scorpio® TS cementless press-fit stem presented significant clinical and functional improvement (p
